=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700512456
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUSTIN ROGER CHEW DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2022
-----------------------------------------------------
Last Update Date | 01/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 SIERRA COLLEGE DR STE 110
-----------------------------------------------------
City | GRASS VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95945-5083
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-790-7597
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9455 CROCKER RD
-----------------------------------------------------
City | GRANITE BAY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95746-6740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-790-7597
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 2901601517
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DDS109896
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------